Failure to Ensure Consistent Oxygen Therapy per Care Plan
Penalty
Summary
The facility failed to ensure that a resident with acute respiratory failure with hypoxia and heart failure was consistently receiving oxygen therapy as outlined in her care plan. Observations revealed that the resident repeatedly turned off her oxygen concentrator in response to alarms, and staff did not intervene or monitor her oxygen use during these incidents. On multiple occasions, the resident was found with the oxygen concentrator turned off and the nasal cannula not in place, despite physician orders for continuous oxygen therapy and a care plan specifying the need for compliance with oxygen use and regular monitoring. Interviews with nursing staff indicated a lack of awareness regarding the resident's current oxygen use and rate, and staff acknowledged that the resident had a pattern of turning the machine on and off independently. The Director of Nursing confirmed that there was no care plan addressing the resident's behavior of disabling the oxygen concentrator and that nurses were not consistently checking the oxygen equipment or assessing the resident each shift as required. Facility policy required comprehensive, person-centered care plans that address identified problems and risk factors, but this was not implemented for the resident's oxygen therapy needs.